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Yu B, Kwak K, Lewandowski RJ, Kim DH. Integration of Ethanol and the Immune Modulator Curcumin for Immunoablation of Hepatocellular Carcinoma. J Vasc Interv Radiol 2024; 35:1033-1042.e11. [PMID: 38513753 DOI: 10.1016/j.jvir.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
PURPOSE To investigate immuno-ethanol ablation using an ethanol and immune adjuvant formulation as a potent immunoablation approach that can achieve an enhanced anticancer effect in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS Ethanol concentration- and exposure time-dependent cellular responses were investigated. Curcumin was combined with ethanol as an immunoablation agent. Cellular uptake of curcumin, cancer cell killing, and inflammatory markers of ethanol-curcumin treatment were characterized. To evaluate the potential in vivo anticancer immunity of ethanol-curcumin treatment, each right and left lobe of rat liver was concurrently inoculated with N1S1 HCC cells and a mixture of treated N1S1 cells (ethanol only or ethanol-curcumin) in Sprague Dawley rats (each group: 5 rats; control: nontreated N1S1 cells). Tumor growth and immune response were characterized with 7T magnetic resonance (MR) imaging, flow cytometry analysis, and immunohistology. RESULTS An optimized ethanol-curcumin (10% ethanol and 0.5% weight/volume (w/v) curcumin solution) treatment contributed to an enhanced cellular uptake of curcumin, increased cancer cell killing, and decreased inflammatory reaction. Ethanol-curcumin-treated N1S1 cell implantation in the rat liver demonstrated N1S1 HCC tumor rejection. The secondary tumor growth by nontreated N1S1 cell inoculation was significantly suppressed at the same time. Activated anticancer immunity was evidenced by significantly increased CD8+ T cell infiltration (3.5-fold) and CD8+-to-regulatory T cell ratio (4.5-fold) in the experimental group compared with those in the control group. CONCLUSIONS Enhanced anticancer effect of immuno-ethanol ablation could be achieved with ethanol-curcumin agent. The results underscore the importance of optimized immunoablation therapeutic procedures for enhanced therapeutic outcomes.
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Affiliation(s)
- Bo Yu
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kijung Kwak
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dong-Hyun Kim
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois; Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois; Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, Illinois.
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Marya NB, Levy MJ. EUS-guided intratumoral therapies: more time on the treadmill. Gastrointest Endosc 2022; 95:1264-1267. [PMID: 35410729 DOI: 10.1016/j.gie.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/19/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Neil B Marya
- UMass Chan Medical School, Worcester, Massachusetts, USA
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3
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Tan T, Shen Z, Wang Y, Guo Z, Hu J, Zhang Y. Self-assembly of pentapeptides in ethanol to develop organogels. SOFT MATTER 2020; 16:10567-10573. [PMID: 33079116 DOI: 10.1039/d0sm01303j] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Organogels have a wide variety of applications in the fields of chemistry, electricity, biomedicine and environmental engineering, which call for robust strategies for designing and developing novel organogelators. Here, we reported a pentapeptide, ECAYF, which was capable of forming a self-healing ethanol gel exhibiting viscoelastic and solid-like properties. The ethanol gel of ECAYF was stable for at least several months, suggesting strong non-covalent interactions between ethanol and the peptide in the gel. In the ethanol gel, self-assembled peptide fibrils were found to immobilize the ethanol molecules for gelation. Results also suggested that the EAF-5 peptide adopted H-bonding β-sheet secondary structures, which further assembled into fibrils. Meanwhile, the self-assembly of the ECAYF peptide in mixtures of differently fractioned ethanol and H2O was observed, which clearly indicated that ethanol promoted the assembly of ECAYF in the solutions. These findings are helpful in understanding the roles of organic solvents as well as the complicated interactions between the solvent and gelator molecules in gelation.
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Affiliation(s)
- Tingyuan Tan
- Key Laboratory of Interfacial Physics and Technology, Shanghai Institute of Applied Physics, Chinese Academy of Sciences, Shanghai 201800, China.
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4
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Abstract
"Endoscopic ultrasound (EUS)-guided ablative therapies have advanced significantly and have led to experimental applications in locations that have been difficult to image and/or reach with percutaneous approaches, such as the caudate and left lobe of the liver. EUS-guided treatments of the liver are under development. The literature has shown that many percutaneous ablative techniques are readily adaptable for EUS. In this review, the authors discuss the current developments on EUS-guided ablation of liver tumors, including injection of sclerosants, thermal therapy, and EUS-guided portal injection of chemotherapy."
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Affiliation(s)
- Tiffany Chua
- Division of Gastroenterology and Hepatology, Mayo Clinic Phoenix, Phoeniz, AZ, USA
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic Phoenix, Phoeniz, AZ, USA.
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5
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Jiang T, Chai W. Endoscopic ultrasonography (EUS)-guided laser ablation (LA) of adrenal metastasis from pancreatic adenocarcinoma. Lasers Med Sci 2018; 33:1613-1616. [PMID: 29362927 DOI: 10.1007/s10103-018-2449-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/15/2018] [Indexed: 12/18/2022]
Abstract
Endoscopic ultrasonography (EUS)-guided laser ablation (LA) is potentially applicable to tumours in the left lobe of the liver and pancreas. This report seeks to introduce the novel use of EUS-guided LA for left adrenal metastases from pancreatic adenocarcinoma. A 70-year-old female was referred to our hospital for dull abdominal pain and tiredness for 1 month. Computed tomography (CT) discovered a 1.0 × 1.7 cm mass in the area of the left adrenal gland. The lesion was highly suspicious for metastasis due to her history of pancreatic adenocarcinoma 1 year ago, which was removed through radical surgery. Intraoperative frozen-section pathology revealed a tumour invading the left adrenal gland. The left adrenal mass was clearly visualised on EUS and exhibited irregular hyper-enhancement during contrast. The tumour was successfully treated by four sessions of EUS-guided LA. After the procedure, symptomatic relief was achieved and remained. At the 4-month follow-up, contrast-enhanced CT revealed that the volume of the target was significantly decreased. Here, we introduced a new method for left adrenal metastasis using thermal ablation through EUS. As a potential alternative access to the percutaneous approach, EUS-guided LA may provide a minimally invasive treatment to relieve the tumour burdens and symptoms when applied accurately.
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Affiliation(s)
- Tian'an Jiang
- Department of Ultrasonography, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China
| | - Weilu Chai
- Department of Ultrasonography, The First Affiliated Hospital, College of Medicine, Zhejiang University, #79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, People's Republic of China.
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6
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Lakhtakia S. Therapy of Pancreatic Neuroendocrine Tumors: Fine Needle Intervention including Ethanol and Radiofrequency Ablation. Clin Endosc 2017; 50:546-551. [PMID: 29207860 PMCID: PMC5719904 DOI: 10.5946/ce.2017.167] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 12/17/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are increasingly being detected, though usually as incidental findings. Majority of the PNETs are non-functional and surgical resection is the standard of care for most of them. However, in patients with small PNETs localized within the pancreas, who are unfit or unwilling for surgery, alternate methods of treatment are needed. Direct methods of ablation of PNETs, using either ethanol injection or radiofrequency ablation (RFA), are emerging as effective methods. The limited literature available as case reports or case series on endoscopic ultrasound (EUS)-guided local ablation using either ethanol or RFA has demonstrated safety and efficacy along with short- to medium-term sustained relief. Long-term benefits with these local ablative therapies are awaited. Comparative studies are needed to show which of these two competing technologies is superior. Finally, comparative trials of EUS-guided ablation with surgical resection in terms of efficacy and safety will ensure their place in the management algorithm.
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Affiliation(s)
- Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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7
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Koklu S, Basar O, Brugge WR. Endoscopic ultrasound guided tumor directed therapy and cyst ablation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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Development of enhanced ethanol ablation as an alternative to surgery in treatment of superficial solid tumors. Sci Rep 2017; 7:8750. [PMID: 28821832 PMCID: PMC5562881 DOI: 10.1038/s41598-017-09371-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/27/2017] [Indexed: 12/11/2022] Open
Abstract
While surgery is at the foundation of cancer treatment, its access is limited in low-income countries. Here, we describe development of a low-cost alternative therapy based on intratumoral ethanol injection suitable for resource-limited settings. Although ethanol-based tumor ablation is successful in treating hepatocellular carcinomas, the necessity for multiple treatments, injection of large fluid volumes, and decreased efficacy in treatment of non-capsulated tumors limit its applicability. To address these limitations, we investigated an enhanced ethanol ablation strategy to retain ethanol within the tumor through the addition of ethyl cellulose. This increases the viscosity of injected ethanol and forms an ethanol-based gel-phase upon exposure to the aqueous tumor environment. This technique was first optimized to maximize distribution volume, using tissue-simulating phantoms. Then, chemically-induced epithelial tumors in the hamster cheek pouch were treated. As controls, pure ethanol injections of either four times or one-fourth the tumor volume induced complete regression of 33% and 0% of tumors, respectively. In contrast, ethyl cellulose-ethanol injections of one-fourth the tumor volume induced complete regression in 100% of tumors. These results contribute to proof-of-concept for enhanced ethanol ablation as a novel and effective alternative to surgery for tumor treatment, with relevance to resource-limited settings.
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9
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Lakhtakia S, Seo DW. Endoscopic ultrasonography-guided tumor ablation. Dig Endosc 2017; 29:486-494. [PMID: 28171697 DOI: 10.1111/den.12833] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
Abstract
Real-time guidance of needle advancement has transformed endoscopic ultrasound (EUS) from a diagnostic to an interventional procedure. EUS-guided fine-needle puncture has application in various interventional procedures (drainage of pseudocyst, biliary intervention, and injection of drugs). Celiac plexus or ganglion neurolysis for pain control is the major current EUS-guided fine-needle injection procedure. Feasibility and safety to accurately position needle devices and/or inject under real-time EUS imaging with precise delivery of interventional agent have expanded the use of EUS to ablate tumors. These include radiofrequency ablation, or delivery of fiducial markers, potential antitumor agents, or radioactive seeds, in the cancer mass. Minimally invasive EUS-guided antitumor therapy is primarily used for pancreatic cancer because of better anatomic access (vs other imaging modality) and the dismal prognosis (despite improvements in surgery and chemoradiation). Also, the response to parenteral chemotherapy in pancreatic cancer is poor because of suboptimal drug delivery resulting from hypovascularity and abundant desmoplasia. Other targets for EUS-guided tumor ablation are pancreatic neuroendocrine tumor and pancreatic cyst lesion, which are less aggressive and curable by resection. However, patients non-eligible for surgery may benefit from local EUS-guided ablation.
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Affiliation(s)
- Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
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10
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Signoretti M, Valente R, Repici A, Delle Fave G, Capurso G, Carrara S. Endoscopy-guided ablation of pancreatic lesions: Technical possibilities and clinical outlook. World J Gastrointest Endosc 2017; 9:41-54. [PMID: 28250896 PMCID: PMC5311472 DOI: 10.4253/wjge.v9.i2.41] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/12/2016] [Accepted: 12/09/2016] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP)-guided ablation procedures are emerging as a minimally invasive therapeutic alternative to radiological and surgical treatments for locally advanced pancreatic cancer (LAPC), pancreatic neuroendocrine tumours (PNETs), and pancreatic cystic lesions (PCLs). The advantages of treatment under endoscopic control are the real-time imaging guidance and the possibility to reach a deep target like the pancreas. Currently, radiofrequency probes specifically designed for ERCP or EUS ablation are available as well as hybrid cryotherm probe combining radiofrequency with cryotechnology. To date, many reports and case series have confirmed the safety and feasibility of that kind of ablation technique in the pancreatic setting. Moreover, EUS-guided fine-needle injection is emerging as a method to deliver ablative and anti-tumoral agents inside the tumuor. Ethanol injection has been proposed mostly for the treatment of PCLs and for symptomatic functioning PNETs, and the use of gemcitabine and paclitaxel is also interesting in this setting. EUS-guided injection of chemical or biological agents including mixed lymphocyte culture, oncolytic viruses, and immature dendritic cells has been investigated for the treatment of LAPC. Data on the long-term efficacy of these approaches, and large prospective randomized studies are needed to confirm the real clinical benefits of these techniques for the management of pancreatic lesions.
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11
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Hara K, Hara K, Yamao K, Yamao K, Mizuno N, Mizuno N, Hijioka S, Hijioka S, Imaoka H, Imaoka H, Tajika M, Tajika M, Tanaka T, Tanaka T, Ishihara M, Ishihara M, Sato T, Sato T, Okuno N, Okuno N, Hieda N, Hieda N, Yoshida T, Yoshida T, Niwa Y, Niwa Y. Development of a new reagent for endoscopic ultrasound-guided celiac plexus neurolysis and tumor ablation therapy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamitu Sato
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamitu Sato
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobuhiro Hieda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobuhiro Hieda
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tukasa Yoshida
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
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Kaplan J, Khalid A, Cosgrove N, Soomro A, Mazhar SM, Siddiqui AA. Endoscopic ultrasound-fine needle injection for oncological therapy. World J Gastrointest Oncol 2015; 7:466-72. [PMID: 26691224 PMCID: PMC4678393 DOI: 10.4251/wjgo.v7.i12.466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/11/2015] [Accepted: 10/12/2015] [Indexed: 02/05/2023] Open
Abstract
The minimal invasiveness and precision of endoscopic ultrasound (EUS) has lead to both its widespread use as a diagnostic and staging modality for gastrointestinal and pancreaticobiliary malignancies, and to its expanding role as a therapeutic modality. EUS-guided celiac plexus neurolysis is now a well-accepted modality for palliation of pain in patients with pancreatic cancer. EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described as methods of performing minimally invasive oncological therapy. EUS-fine needle injection may be performed as adjunctive, alternative, or palliative treatment. This review summarizes the studies to date that have described these methods. A literature search using the PubMed/MEDLINE databases was performed. While most published studies to date are limited with disappointing outcomes, the concept of a role of EUS in oncological therapy seems promising.
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Yoon WJ, Seo DW. [Endoscopic Ultrasound-guided Local Therapy of Pancreatic Tumors]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:154-8. [PMID: 26387698 DOI: 10.4166/kjg.2015.66.3.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The development of curvilinear EUS has enabled EUS-guided fine-needle aspiration of intra-abdominal mass lesions. With the introduction of interventional EUS, this technology has undergone several modifications in order to be applied to clinical medicine. One of the potential uses of interventional EUS is the EUS-guided local therapy of pancreatic tumors. Various treatment modalities such as fine-needle injection, radiofrequency ablation, photodynamic therapy, laser ablation, and brachytherapy have been tried under EUS guidance. Some of these modalities are being applied clinically. These methods for EUS-guided local therapy of pancreatic tumors will be reviewed in this article.
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Affiliation(s)
- Won Jae Yoon
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chantarojanasiri T, Aswakul P, Prachayakul V. Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent. World J Gastrointest Endosc 2015; 7:960-968. [PMID: 26265989 PMCID: PMC4530329 DOI: 10.4253/wjge.v7.i10.960] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/04/2015] [Accepted: 07/08/2015] [Indexed: 02/05/2023] Open
Abstract
There is an increasing role for endoscopic ultrasound (EUS)-guided interventions in the treatment of many conditions. Although it has been shown that these types of interventions are effective and safe, they continue to be considered only as alternative treatments in some situations. This is in part due to the occurrence of complications with these techniques, which can occur even when performed by experienced endosonographers. Although common complications have been described for many procedures, it is also crucial to be aware of uncommon complications. This review describes rare complications that have been reported with several EUS-guided interventions. EUS-guided biliary drainage is accepted as an alternative treatment for malignant biliary obstruction. Most of the uncommon complications related to this procedure involve stent malfunction, such as the migration or malposition of stents. Rare complications of EUS-guided pancreatic pseudocyst drainage can result from air embolism and infection. Finally, a range of uncommon complications has been reported for EUS-guided celiac plexus neurolysis, involving neural and vascular injuries that can be fatal. The goal of this review is to identify possible complications and promote an understanding of how they occur in order to increase general awareness of these adverse events with the hope that they can be avoided in the future.
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Sharma V, Rana SS, Bhasin DK. Endoscopic ultrasound guided interventional procedures. World J Gastrointest Endosc 2015; 7:628-42. [PMID: 26078831 PMCID: PMC4461937 DOI: 10.4253/wjge.v7.i6.628] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/24/2015] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.
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Widmer JL, Michel K. Endoscopic Ultrasound-Guided Treatment beyond Drainage: Hemostasis, Anastomosis, and Others. Clin Endosc 2014; 47:432-9. [PMID: 25325004 PMCID: PMC4198561 DOI: 10.5946/ce.2014.47.5.432] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.
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Affiliation(s)
- Jessica L Widmer
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Kahaleh Michel
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
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17
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Abstract
OPINION STATEMENT Endoscopic ultrasound (EUS) is not only a diagnostic tool but also an interventional and therapeutic procedure. Indeed, in addition to tissue acquisition, it can also drain fluid collections adjacent to the gastrointestinal tract, provide access to biliary and pancreatic ducts, biliary, pancreatic, and gallbladder drainage, pancreatic cyst ablation, and, finally, provide anti-tumoral treatments and interventional vascular procedures. Although several improvements have been made in the last decade, the full potential of interventional EUS is yet to be completely explored. Future areas of research are the development of dedicated tools and accessories, the standardization of the interventional procedures, and the widening of the use of EUS, while increasing the expertise worldwide. In addition, more data, based on well-performed, possibly randomized clinical trials, are needed to accurately determine the risks and long-term outcomes of these interventions. We firmly believe that interventional EUS can play a pivotal role in anti-tumor treatments, by the fine-needle injection of anti-tumoral agents, tumor ablation, and assisting radiation treatment with gold fiducial placement and the implantation of intralesional seeds. The goal of the near future will be to offer targeted therapy and monitoring of tumor treatment response in a more biologically driven manner than has been available in the past. Interventional EUS will be an essential part of the multidisciplinary approach to cancer treatment.
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18
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Zhang WY, Li ZS, Jin ZD. Endoscopic ultrasound-guided ethanol ablation therapy for tumors. World J Gastroenterol 2013; 19:3397-3403. [PMID: 23801831 PMCID: PMC3683677 DOI: 10.3748/wjg.v19.i22.3397] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/05/2013] [Accepted: 05/19/2013] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a diagnostic modality nearly three decades ago. In particular, EUS-guided fine-needle injection has proven a successful minimally invasive approach for treating benign lesions such as pancreatic cysts, relieving pancreatic pain through celiac plexus neurolysis, and controlling local tumor growth of unresectable malignancies by direct delivery of anti-tumor agents. One such ablative agent, ethanol, is capable of safely ablating solid or cystic lesions in hepatic tissues via percutaneous injection. Recent research and clinical interest has focused on the promise of EUS-guided ethanol ablation as a safe and effective method for treating pancreatic tumor patients with small lesions or who are poor operative candidates. Although it is not likely to replace radical resection of localized lesions or systemic treatment of metastatic tumors in all patients, EUS-guided ablation is an ideal method for patients who refuse or are not eligible for surgery. Moreover, this treatment modality may play an active role in the development of future pancreatic tumor treatments. This article reviews the most recent clinical applications of EUS-guided ethanol ablation in humans for treating pancreatic cystic tumors, pancreatic neuroendocrine tumors, and metastatic lesions.
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MESH Headings
- Ablation Techniques
- Endosonography
- Ethanol/administration & dosage
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Neuroendocrine Tumors/diagnostic imaging
- Neuroendocrine Tumors/pathology
- Neuroendocrine Tumors/surgery
- Pancreatic Cyst/diagnostic imaging
- Pancreatic Cyst/pathology
- Pancreatic Cyst/surgery
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Treatment Outcome
- Ultrasonography, Interventional/methods
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Yoon WJ, Brugge WR. Endoscopic ultrasonography-guided tumor ablation. Gastrointest Endosc Clin N Am 2012; 22:359-69, xi. [PMID: 22632957 DOI: 10.1016/j.giec.2012.04.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
With the introduction of curvilinear endosonoscopes, endoscopic ultrasonography (EUS) has achieved the role of a therapeutic modality as well as diagnostic procedure. EUS-guided tumor ablation is one such therapeutic modality. Various techniques of EUS-guided tumor ablation have been described, including radiofrequency ablation, photodynamic therapy, laser ablation, and ethanol injection. Most of the currently described techniques are experimental. Development and continuous improvement of devices, as well as establishment of indications for EUS-guided tumor ablations, are mandatory.
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Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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20
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Abstract
The development of linear-array endoscopic ultrasonography (EUS), with its real-time guidance of needle advancement, changed EUS from a diagnostic procedure to an interventional procedure. EUS-guided fine-needle injection (EUS-FNI) is an attractive minimally invasive delivery system with potential applications in local (intratumoral) and combination therapy against esophageal and pancreatic cancers. The evidence of the feasibility of EUS-FNI of antitumor agents has been expanding with promising results.
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21
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Verna EC, Dhar V. Endoscopic ultrasound-guided fine needle injection for cancer therapy: the evolving role of therapeutic endoscopic ultrasound. Therap Adv Gastroenterol 2011; 1:103-9. [PMID: 21180519 DOI: 10.1177/1756283x08093887] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound (EUS) is central to the diagnosis and staging of many malignancies, but now has an evolving role in cancer therapy. EUS-guided fine needle injection (FNI) is already used for palliative interventions such as treatment of pain through nerve blockade and to guide biliary decompression when conventional ERCP is not possible. More recently, EUS-FNI has been used to deliver specific anti-tumor agents for pancreatic cyst ablation and local control of tumor growth in patients with unresectable solid malignancies. The agents used to date include ethanol, brachytherapy seeds, and chemotherapeutic agents such as paclitaxel. In addition, FNI of new immunomodulating cell cultures such as mixed lymphocyte and dendritic cell cultures has also been reported, as has FNI of several different viral vectors for antitumor therapy. Although experience with these agents remains preliminary, EUS-FNI is a minimally invasive approach to deliver local antitumor agents, and is likely to have an expanding role in cancer therapy.
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Affiliation(s)
- Elizabeth C Verna
- Columbia University Medical Center, 161 Ft. Washington Ave., Herbert Irving Pavillion 8th Floor, New York, NY 10032, USA
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22
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DeWitt J, Mohamadnejad M. EUS-guided alcohol ablation of metastatic pelvic lymph nodes after endoscopic resection of polypoid rectal cancer: the need for long-term surveillance. Gastrointest Endosc 2011; 74:446-7. [PMID: 21481867 DOI: 10.1016/j.gie.2011.01.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 01/27/2011] [Indexed: 02/08/2023]
Affiliation(s)
- John DeWitt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
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23
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Abstract
Endoscopic ultrasound (EUS) is a very useful modality for the diagnosis and staging of pancreatic masses. With the advent of EUS-guided fine-needle aspiration technology, this modality has made a tremendous leap from imaging modality to histologic diagnosis and therapeutic intervention. EUS offers high-resolution images of and unparalleled access to the pancreas. After locating the tip of the echoendoscope in the duodenum or stomach, several drugs or local treatment modalities can be delivered directly into the pancreas. EUS-guided ethanol lavage with/without paclitaxel injection has been tested for the treatment of cystic tumors of the pancreas, with complete resolution of cystic tumor being observed in up to 70-80% of patients. Ethanol injection is also performed for the management of solid neuroendocrine tumors of the pancreas. Various type of EUS-guided injection have also been investigated for the treatment of pancreatic cancer. An activated allogenic mixed lymphocyte culture (Cytoimplant) was injected in patients with advanced pancreatic cancer. A replication-deficient adenovirus vector carrying the tumor necrosis factor-alpha gene was also delivered intratumorally by EUS. ONYX-015 is an oncolytic attenuated adenovirus that exhibits replication preferentially in malignant cells, causing cell death, and this has also been injected into pancreatic cancers under EUS guidance. EUS-guided local ablation therapies such as radiofrequency ablation, photodynamic therapy, and brachytherapy are also under investigation. EUS-guided fine-needle injection for various solid or cystic lesions is a rapidly expanding field. This article reviews the various applications of EUS for the treatment of pancreatic tumors.
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Affiliation(s)
- Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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24
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EUS-guided pancreas ablation: is the sky really the limit? Gastrointest Endosc 2010; 72:364-5. [PMID: 20674624 DOI: 10.1016/j.gie.2010.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 04/17/2010] [Indexed: 02/08/2023]
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25
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Abstract
Endoscopic ultrasound (EUS) is an increasingly available diagnostic and therapeutic tool used within the U.K. it has wide applications both in the gastrointestinal tract and mediastinum with its current main uses being in the staging of luminal malignancies and assessment of pancreatic and subepithelial lesions. The emergence of linear EUS has opened up new therapeutic avenues with fine needle aspiration, trucut biopsies, coeliac plexus blocks and transmural pseudocyst drainage all now possible. Future developments include localised brachytherapy/chemotherapy and alcohol ablation of unresectable pancreatic malignancies and EUS-guided endoscopic surgery.
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Tarantino I, Barresi L. Interventional endoscopic ultrasound: Therapeutic capability and potential. World J Gastrointest Endosc 2009; 1:39-44. [PMID: 21160649 PMCID: PMC2999076 DOI: 10.4253/wjge.v1.i1.39] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 03/09/2009] [Accepted: 03/16/2009] [Indexed: 02/05/2023] Open
Abstract
The linear echoendoscope, introduced in the 1990s, opened the era of interventional endoscopic ultrasound (IEUS). The linear echoendoscope enabled EUS guided Fine Needle Aspiration (EUS-FNA) allowing the path of the needle to be traced during the puncture process. After EUS-FNA, other interventional procedures were introduced in clinical practice. Tissue acquisition was the first EUS-guided interventional procedure and its higher diagnostic quality has undoubtedly been established. After EUS-FNA, Celiac plexus neurolysis (CPN) and block (CPB), pancreatic pseudocyst drainage, abdominal and mediastinal collections/abscesses drainage, and in selected cases, pancreatic and biliary ductal system drainage, were introduced in clinical practice. EUS-guided fine needle injection with local delivery of antitumor agents is considered a promising modality. We have reviewed published data on EUS guided interventional procedures with the object of summarizing the diagnostic capability of endoscopic ultrasound and elaborates in detail its therapeutic capability and potential.
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Affiliation(s)
- Ilaria Tarantino
- Ilaria Tarantino, Luca Barresi, Gastroenterology and Endoscopy Department, Medicine University of Pittsburgh Medical Center/Mediterranean Institute for transplantation and Specialized Therapies, Palermo 90127, Italy
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27
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Irisawa A, Hikichi T, Shibukawa G, Takagi T, Imamura H, Ohira H. Interventional endoscopic ultrasonography: applications for cancer related treatment. Dig Endosc 2009; 21 Suppl 1:S57-60. [PMID: 19691737 DOI: 10.1111/j.1443-1661.2009.00865.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
For tissue diagnosis in patients with abnormalities of various organs, endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA) has emerged as an effective technique. Subsequently, EUS-guided fine needle injection (EUS-FNI) has expanded the clinical utility of EUS. Several applications of EUS-FNI for anti-cancer efforts have included celiac nerve blocking and drug delivery into tumors, such as ablation, chemotherapy, gene therapy, and cytoimplantation. Furthermore, chemosensitivity tests with materials obtained using EUS-FNA are available to produce tailor-made medicines. Demonstrably, EUS-guided intervention has opened new and exciting clinical applications for the management of malignancies.
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Affiliation(s)
- Atsushi Irisawa
- Department of Internal Medicine, Fukushima Medical University School of Medicine, Japan.
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28
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Abstract
Needlescopic adrenal ablative therapy is an attractive therapeutic option for the management of small adrenal masses. The spectrum of neoplasms that can be ablated includes isolated solid organ metastases (lung, kidney, liver), nonisolated but symptomatic (painful) adrenal metastasis, and small, nonmetastatic, hormonally active adrenal tumors. Moreover, needlescopic ablation offers an effective minimally morbid intervention for patients who are poor surgical candidates either due to advanced age and/or significant comorbid conditions. Ablative techniques described to date include radiofrequency ablation (RFA), cryoablation, and chemical ablation. Most procedures can be performed under percutaneous radiographic guidance on an outpatient basis. By and large, the bulk of clinical experience with adrenal ablation pertains to RFA. Successful ablation is usually dependent upon lesion size, with tumors 5 cm or smaller demonstrating the highest successful ablation rates. The most frequently described adverse sequelae of adrenal ablation are local tumor recurrences. However, many of these local recurrences can be managed by repeat ablation, with patients demonstrating durable oncologic outcomes.
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Affiliation(s)
- Eric Lauer
- Penn State Milton S. Hershey Medical Center, Division of Urology, 500 University Drive, C4830B, Hershey, PA 17033, USA
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29
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Artifon ELA, Lopes RI, Kumar A, Lucon AM, Dall'oglio M, Hawan B, Sakai P, Srougi M. Endoscopic ultrasound facilitates histological diagnosis of renal cell cancer. J Endourol 2009; 22:2447-50. [PMID: 19046085 DOI: 10.1089/end.2008.0151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Over two-thirds of renal masses noted incidentally on abdominal CT scans performed for nonurological indications are most likely renal cell carcinoma (RCC). The prognosis in these instances is often quite favorable, as early diagnosis offers the best hope of a complete cure. We report the identification of a RCC incidentally at endoscopic ultrasound (EUS) while an earlier CT scan of abdomen was negative. The mass was biopsied resulting in a histological confirmation of RCC and successful surgical resection.
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Affiliation(s)
- Everson L A Artifon
- Division of Gastroenterology and Department of Urology, University of São Paulo School of Medicine, São Paulo, Brazil
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30
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Brugge WR. EUS-guided tumor ablation with heat, cold, microwave, or radiofrequency: will there be a winner? Gastrointest Endosc 2009; 69:S212-6. [PMID: 19179160 DOI: 10.1016/j.gie.2008.12.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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31
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Abstract
Endoscopic ultrasound was initially introduced in the 1980s as a diagnostic modality using echoendoscopes with radial scanning that permitted reconstruction of cross-sectional images similar to computed tomography The close proximity of the ultrasound transducer to the gastrointestinal wall and retroperitoneal structures allowed a detailed examination that is not possible with cross-sectional imaging such as computed tomography and magnetic resonance imaging. It proved to be highly accurate and useful in the staging of gastrointestinal malignancies, as well as in characterizing the nature of subepithelial lesions and disorders of the pancreaticobiliary system. The introduction of linear echoendoscopes facilitated fine needle aspiration because, with linear scanning, it was able to trace the path of the tip of the needle during the puncture process. In addition to being very useful for tissue acquisition for diagnostic purposes, the principles behind endoscopic ultrasound-guided fine needle aspiration paved the way for the development of therapeutic endoscopic ultrasound. Substances could now be delivered by endoscopic ultrasound into targeted areas, an example being an endoscopic ultrasound-guided celiac plexus block and neurolysis. In addition, the endoscopic ultrasound-guided puncture of fluid collections, abscesses and obstructed biliary and pancreatic ductal systems facilitated the passage of guidewires, thus allowing therapeutic drainage procedures to be performed using the Seldinger technique. This review summarizes the diagnostic capability of endoscopic ultrasound and then moves on to elaborate in detail its therapeutic capability and potential.
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Affiliation(s)
- Tiing Leong Ang
- Division of Gastroenterology, Department of Medicine, Changi General Hospital, Singapore.
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